Module 6: Chapters 47 to 60 Flashcards
Phases of the Menstrual Cycle: Follicular
each follicule in an ovary contains an oocyte. Follicle stimulating hormone (FSH) spurs follicle development by the end of the phase.
-the surge in estrogen causes luteinizing hormone and FSH to increase
Phases of the Menstrual Cycle: Ovulatory
the LH surge triggers ovulation 24-36 hrs later. Ovulation is the release of the egg from the ovary
Phases of the Menstrual Cycle: Luteal
the start of ovulation begins the luteal (last) phase, which lasts ~14 days, progesterone is dominant in this phase
what are some things to do for preconception health?
-increase folic acid (folate, vitamin B9) 400 mcg = 600 mcg when prego. folate deficiency can cause birth defects of the brain and spinal cord (neural tube defects)
-stop smoking, illicit drugs and alcohol
-keep vaccinations current
Drospirenone oral contraceptive
-progestin that is used in some COCs to reduce AEs commonly seen with oral contraceptives.
-it has a mild potassium sparing diuretic which decreases bloating
Progesterone only pills
-contain no estrogen and have 28 days of active pills
-prevent pregnancy by suppressing ovulation, thickening the cervical mucus to inhibit sperm penetration and thinning the endometrium
-needs good adherence: must be taken within 3 hours of the scheduled time
-safe in women who have migraines with aura
general tips for contraceptive names
-Lo: < 35 mcg of estrogen; less estrogen = less estrogenic SEs
-Fe: iron supplement is included
-24: shorter placebo time: 24 active + 4 placebo = 28 day cycle
Severe & rare AEs of estrogen (ACHES)
A: abdominal pain that is severe - can indicate a ruptured liver tumor or cyst, mesenteric or pelvic vein thrombosis, or the pain could be due to liver or gallbladder issue
C: chest pain- sharp, crushing or heavy pain can indicate a heart attack, SOB can indicate a PE
H: headaches- sudden and severe with vomiting or weakness/numbness on one side of the body can indicate a stroke
E: eye problem- blurry vision, flshing lights or partial/complete vision loss can indicate a blood clot in the eye
S: swelling or sudden leg pain- can indicate a DVT
BBW of hormonal contraceptives
BBW:
–> all estrogen-containing products (pils, patch, ring): do NOT use in women > 35 yrs old who smoke due to risk of serious cardio events
–> estrogen + progestin transdermal patch: do not use in women with a BMI > 30 kg/m2 (due to increased risk of thromboembolism) or dec effect (twirla)
–> Depo-Provera: loss of bone mineral density with long terms use
DO not use estrogen with these conditions:
-hx of DVT/PE, stroke, CAD
-hx of breast, ovarian or liver cancer
-severe headache or migraines with aura
drug interactions that DECREASE hormonal contraception efficacy
-abx (rifampin–> use back up method for 6 weeks after use, rifabutrin, rifapentine) strong inducers
-anticonvulsants (carbamazepine, oxacarbazepine, phenytoin, primidone, topiramate, lamotrigine)
-st johns wort
-smoking tobacco
-ritonavir
drug interactions with hormonal contraceptives: risks with hepatitis C tx
-Mavyret cannot be used with any formulation containing ethinyl estradiol due to the risk of liver toxicity
-with all new hep C drugs being dispensed to a pt using contraceptives
Drospirenone drug interactions
risk of increased potassium
Late or missed pills instructions
-start as soon as remembered
-if more than 1 COC pill is missed, back up contraception is required
-if missed pills are in the 3rd week- omit the hormone free week and start the next package of pills right away- back up contraception should be used for 7 days
Emergency contraceptives (3)
1) copper IUD: most effective, use within 5 days, lasts for up to 10 yrs
2) Ullipristal (Ella): more affective than plan B, (less effective > 195 lbs or BMI > 30), uses ASAP or 5 days
3) Levonorgestrel (plan B): less effective if > 165 lbs or BMI > 25, use ASAP/within 3 days, available OTC
infertility drugs act like endogenous hormones to trigger ovulation
-inc LH/FSH = ovulation (release of eggs)
-clomiphene acts as estrogen to inc LH/FSH = causes ovulation
-Aromatase inhibitors suppress estrogen to inc FSH = causes ovulation
-Gonadotopin drugs act as LH, FSH or hcg = causes ovualtion
-can trigger the release of multiple eggs and inc risk of multiple births
what vaccines are recommended for prego pts
-inactivated influenza
-single dose of Tdap
Teratogens in pregnancy: acne meds
-isotretinoin
-topical retinoids
Teratogens in pregnancy: antibiotics
-qionolones
-tetracyclines
Teratogens in pregnancy: anticoagulants
warfarin
Teratogens in pregnancy: Dyslipidemia, HF and HTN
-statins
-ACE
-ARBS
-aliskiren
-entresto
Teratogens in pregnancy: hormones
-estradiol
-progesterone
-raloxofene
-Duavee
-testosterone
-contraceptives
Teratogens in pregnancy: Migraine
-dihydroegotamine
-ergotamine
Teratogens in pregnancy: others
-hydroxyurea
-lithium
-methotrexate
-misoprostol
-NSAIDs
-Paroxetine
-Ribavirin
-Thalidomide
-Topiramate
-weight loss drugs
-valproic acid/divalproex
what is preeclampsia?
-complication of pregnancy that presents with elevated BP & evidence of organ damage (kidney/liver)
-if not treated, can lead to eclampsia which can lead to eclampsia - can lead to seizure/death
-only cure is delivery of baby
how do you prevent preeclampsia?
adding low dose ASA at the end of the firs trimester for women at risk (risk factors = DM 1 or 2, renal disease, hx of preeclampsia, chronic HTN)
Management in Pregnancy: morning sickness/M/V
-lifestyle: smaller frequent meals, water, avoid spicy foods
-pyridoxine (vit B6) +/- doxylamine
-RX: doxylamine/pyridoxine (Bonjesta, Diclegis)
Management in Pregnancy: GERD/Heartburn
-eat smaller, more frequent meals, not eating 3 hrs prior to sleep
-tums (if not working, can add on PPI or H2)
Management in Pregnancy: flatulence
simethicone (gasX, Mylicon)
Management in Pregnancy: Constipation
-inc fluid intake, inc fiber and physical activity
-fiber (psyllium, calcium polycarbophil, methylcellulose)
-docusate and polyphethylene glycol are used to prevent and treat constipation
Management in Pregnancy: Cold, cough, allergies
-1st line: cromolyn
-2nd line: 1st gen antihistamines: chlopheriramine and diphenhydramine
-allergy: budesonide and beclomethasone are preferred
Management in Pregnancy: Pain
-1st line: acetaminophen
-AVOID NSAIDs
Management in Pregnancy: Asthma
-budesonide
-rescue (inhaled albuterol)
Management in Pregnancy: HTN
-labetalol
-methyldopa
-nifedipine
Management in Pregnancy: DM
insulin is preferred
-metformine and glyburide
Management in Pregnancy: infections
-penicillins, cephalosporins, erythromycin and azithromycin are safe
–> vag funcgal: topical antifungals x 7 days (avoid fluconazole)
–> UTI: cephalexin 500 mg x7, ampicillin 500 mg x 7,
-last line = nitrofurantoin, bactrim during 1st trimester, NOT BE USED during the last 2 days of pregnancy
Management in Pregnancy: conditions needing anticoagulation
VTE:
–> tx: LMWH
–> proh: pneumatic conpression +/- LMWH
-warfarin is teratogenic (can be switched back after 13th week if has mechanical valve)
Management in Pregnancy: hypothyroidism
-levothyroxine (will require 30-50% dose increase)
Management in Pregnancy: hyperthyroidism
-graves disease: propylthiouracil
-methimazole also used
what meds should be avoided while breastfeeding?
-amphetamines
-amiodarone
-ergotamines
-lithium
-metronidazole
-phenobarbital
-statins
Factors that have osteoporosis risk: patient characteristics
-advanced age
-ethnicity (caus and asians at higher risk)
-family hx
-sex (females)
-low body weight
Factors that have osteoporosis risk: Medical diseases/conditions
-DM
-eating disorders
-GI disease (IBD, celiac disease, gastric bypass, malabsorption syndrome)
-hyperthyroidism
-hypogonadism in men
-menopause
-rheumatoid arthritis, autoimmune disease
-others: epilepsy, HIV/AIDS, parkinson disease
Factors that have osteoporosis risk: Lifestyle factors
-smoking
-excessive alcohol intake (3 drinks/day)
-low calcium intake
-low vit D intake
-physical inactivity
Factors that have osteoporosis risk: Medication
-anticonvulsants (carbamazepine, phenytoin, phenobarbital)
-aromatase inhibitors
-depo-medroxyprogesterone
-GnRH
-lithium
-PPIs
-Steroids
-thyroid hormone (in excess)
-loops, SSRIs, TZDs
osteoblasts
the cells involved in bone formation
osteoblasts
cells involved in resorption; they break down tissue in the bone
What is a T-score?
-it compares the pts measured BMD to the average peak BMD of a healthy, young, white adult of the same sex
-a DEXA measures BMD so a T-score can be determined
-T scores are negative: a score at or above -1 correkated with stronger (denser) bones, which are less likely to fracture
how. to interprete T- scores
Normal: > -1
Osteopenia: -1 to -24
Osterporosis: < -2.5
who should have BMD measured?
-women > 65 y/o
-men > 70 y/o
-younger patients at high risk for fracture
calcium role in OA:
-rec to take 1,000-1,200 mg elemental ca (do not exceed 500-600 mg/dose)
–> calcium carbonate: (tums)
-40% elemental calcium
-absoprtion: acid dependent
-must take with meals
–> calcium citrate (citracal)
-21% elemental calcium
-absorption: not acid-dependent
-can take with or without food
Vitamin D role in OA:
-required for caclium absorption
-deficiency = serum vitmain D < 25 ng/mL
–> treat deficiency with cholecalciferol (vit D3) OR Ergocalciferol (vit D 2)
- cholecalciferol: 125-175 mcg daily
-ergocalciferol: 1,250 mcg weekly
criteria for initiating treatment in osteoporosis
-T-score < -2.5 in the spine, femoral neck, total hip or 1/3 radius, OR
-presence of a fragility fracture, regardless of BMD
criteria for initiating treatment in osteopenia (high risk)
-low bone density (T score between -1 and -2.5) AND
-FRAX score indicated a 10-yr probability of a major osteoporosis-related fracture > 20% or a 10-yr hip fracture prob > 3%
Treatment of OA: Bisphosphonates
-1st line
-Alendronate (Fosamax) (preven: 5 mg qd, tx: 10 mg qd)
CI: hypocalcemia, inability to stand/sit upright for at least 30 mins
SEs: esophagitis, hypocal, GI effects (rare ones: atypical femur fracture, osteonecrosis of the jaw
-separate from calcium, antacids, iron and mag by at least 2 hrs
TX duration: 3-5 yrs in pts with a low risk of fracture
Treatment of OA: Injectable Bisphosphonates
-Ibandronate (Bonvia) 3 mg IV q 3 months
-Zoledronic acid 5 mg IV once yearly
CI: hypocalcemia
-monitor for renal impairment
*preferred if esophagitis is present
Treatment of OA: Raloxifene
-an estrogen agonist/antagonist (SERM that dec bone resorption) horse estrogen
BBW: inc risk of VTE and death due to stroke
CI: VTE, pregnancy
-SEs: hot flashes, edema, arthralgia, leg cramps
Treatment of OA: Calcitonin
-inhibits bone resorption by osteoclasts
-nasal spray ( 1 qd) or SC/IM: 100 u qd
Warnings: hypocalcemia, inc risk of malignancy, hypersensitivity to salmon-derived products
Treatment of OA: RANKL inhibitor, Denosumab (Prolia)
-prevents osteoclast formation= leads to dec bone absorption and inc bone mass- used in pts with high risk of fracture
-60 mg sc q 6 months
-CI: hypocalcemia, pregnancy
warnings: atypical femur fracture, osteonecrosis of the jaw
-SEs: HTN, fatigue, edema, dysnpea, headache, N/V, dec PO4
Treatment of OA: Romosozumab
-indicated for postmenopausal females w/ hx of an osteoporotic fracture or multiple risk factors - inhibits sclerostin, a protein that blocks bone formation- tx limited to 12 months
-BBW: inc risk of stroke, MI and cardio death
-CI: hypocalcemia
Treatment of OA: Raloxifene (Evista)
-alt to bisphosphonates if high risk of vertebral fractures
-increased risk for VTE and stroke
-can be used if low VTE risk or high breast cancer risk
SEs; vasomotor symptoms
Treatment of OA: Bazedoxifene/Estrogens (Duavee)
-can be used in women with an intact uterus for prevention of osteoporosis
-alsi used as tc for vasomotor symptoms
SE: increased risk of cancer
Hormone therapy for meno, health risk and appropriate use: estrogen
-most effective tx for vasomotor symptoms
-women with a uterus: use in combo with a form of progesterone- unopposed estrogens increases the risk of endometrial cancer
-associated w/ sig risk of VTE, stroke, breast cancer
Hormone therapy for meno, health risk and appropriate use: Progestin
-progestins can be given as part of a combination pill or as seperate tab (medroxyprogesterone)
-can cause mood disturbances, which may be intolerable; if taken intermittently, spotting can occur
-micronized progestins are considered to be dafer than synthetic progestins
Criteria for use of hormone therapy in menopause
-healthy, symptomatic women who are within 10 yrs of menopause, < 60 y/o and have no CI to use
-extending tx beyond 60 yrs may be acceptable if the lowest dose is used.
-consider QOL priorities and personal risk factors - pts with risk factors should use nonhormonal therapy: SSRIs, SNRIs, gaba or pregablin
local hormone therapy products
-17-beta estradiol: estrace, estring, vagifem, premarin
Systemic hormone therapies
-estradiol (Alora, climera)
-MPA
-Prometrium
BBW: endometrial cancer, dementia, inc risk of VTE, stroke, breast cancer
-CI: breast cancer, uterine bleeding, active VTE, pregnancy
SSRI for menopause: Paxil, paroxetine
-used for moderate - severe vasomotor symptoms
Ospemifene (Osphena)
-oral estrogen antagonist/agonist indicated for dyspareunia (painful intercourse) and moderate vaginal dryness
-should be used short term
Testosterone use: androgel and depo-testosterone
BBW: secondary exposure in kids
warnings: inc risk of breast cancer, prostate cancer, cardio events, VTE
SEs: inc appretite, acne, edema, hepatotoxicity, reduced sperm count
What are the key drugs that can cause erectile dysfunction?
- alcohol
-antidepressants (SSRIs, SNRIs)
-antihypertensives (1st gen, cholrpromazine, prolactin-raising 2nd gen (risperidone, paliperidone))
-BPH meds (finesteride, dutaseride, silodosin)
-anticancer drugs (leuprolide, flutamide)
-anticholerlinergics
-H2RAs (climetidine, ranitidine)
-nicotine
-opioids
whar are the natural products that are used to treat ED?
-yohimbe
-L-arginine
-panax ginseng
PDE-5 inhibitors: Sildenafil (viagra)
-on demand dosing: 25-100 mg qd PRN (start at 50 mg, take 1 1/2 hr before sex)
-also used for pulmonary HTN
CI: do not use with nitrates or riociguat
Warnings: hearing loss, color discrimination, vision loss, hypotension, priapism
SEs: headache, fluching, dizziness,
-cna have decreased efficiacy if taken with a high fat or large meal
PDE-s Inhibitors: Tadalafil (Cialis)
-2.5-5 mg daily (on demand dosing: 5-20 mg daily PRN)
-lasts the longest “weekend pill”
CI: do not use with nitrates or riociguat
Warnings: hearing loss, color discrimination, vision loss, hypotension, priapism
SEs: headache, fluching, dizziness,
-crcl 30-50 : 5 mg prn, crcl < 30: 5 mg q 72 hrs
When do you reduce PDE-5 inhibitor doses?
> 65 y/o
using an alpha blocker
using a CYP3A4 inhibitor
severe renal or liver failure
*decrease dose by 50% (V: 25 mg, C: 5 mg)
PDE-5 inhibitor drug interactions
-absolute contraindication: using nitrates = extreme hypotension
-enhance the hypotensive effects of alpha 1 blockers
-alcohol can enhance hypotension
-moderate and strong CYP450 inhibitors (grapefruit juice, protease inhibitors, azole antifungals)
Aloprostadil (Prostagladin) for ED
- a vasodilator that allows blood to flow into the cavernosal arteries, which then enlarges the penis
-either injected into the penis of a pellet is inserted through the urethera
drugs for hypoactive sexual desire disorder: Fibanserin (Addyi)
-100 mg QHS (d/c if no benefits after 8 weeks)
-BBW: CI with alcohol, CYP3A4 inhibitors
Warnings: hypotension, suncope, CNS depression
SEs: dizziness, nausea, fatigue, insomnia, dry mouth
-avoid in pregnancy or if breast feeding
rugs for hypoactive sexual desire disorder: Bremelanotide (Vylessi) injection
-1.75 mg SC PRN, injected 45 min before sextual activity
CI: do not use with uncontrolled hypertension or known cardiovascular disease
Warnings: inc BP, dec HR after each dose
-avoid in pregnancy, effective contraception should ne used
what drugs can worsen BPH?
-centrally-acting anticholergics (bentropine)
-antihistamines
-decongestants
-phenothiazine
-TCAs
-caffeine
-diuretics
-SNRIs
-testosterone products
symptoms and complications of BPH
-hesitancy, interm. urine flow, straining or a weak stream of urine
-urinary urgency and leaking or dribbling
-incomplete emptying of the bladder
non-selective Alpha 1 blockers for BPH:
Doxazosin (Cardura), (XL version mau leave ghost pill in poop)
Terazosin
-should be given at bedtime to help minimize the initial “first dose” effect of orthostasis/dizziness
selective alpha blockers for BPH
-Tamsulosin (Flomax)
-Alfuzosin
-Silodosin (can cause retrograde ejaculation
Alpha 1 blockers class safety/SEs/Monitoring
Warnings: orthostatic hypotension/syncope, intraoperative floppy iris syndrome
SE: dizziness, fatigue, headache, abnormal ejaculation
-alpha blocker can be used for off label for bladder outley obstruction in women
alpha blocker drug interactions
-use caution when giving with PDE-5 inhibitors due to added hypotensive events
-silodosin cannot be used with strong P-gp inhibitors, such as cyclosporine
-alfuzosin can cause QT prolongation
5 alpha reductase inhibitors for BPH: finasteride (Proscar)
-F: 5 mg daily (Propecia used for alopecia)
CI: women of child-bearing potential pregnancy, children
Warnings: may increase risk of high grade prostate cancer
SEs: impotence, dec libido, ejaculation disturbances, breast enlargement and tenderness
–> prego women should not handle these meds
–> tx for 6 months may be required for mx efficacy
Phosphodiesterase-5 Inhibitors for BPH: Tadalafil (cialis)
-5 mg at the same time each day
CI: do not use with nitrates or riociguat
Warnings: hearing loss, vision loss, hypotension, priapism
SE: headache, flushing, dizziness, dyspepsia, back pain
what is urge incontinence?
a sudden and unstoppable urge to urinate. associated with neuropathy and often present in those with DM, strokes, dementia, parkinsons disease or multiple sclerosis
what is stress incontinence?
urine leaks out during any form of exertion as a result of pressure on the bladder
what is mixed incontinence?
combination of urge and stress incontinence
what is functional incontinence?
there is no abnormality in the bladder, but the pt may be cognitively, socially or physically impaired thus hindering access to a toilet
what is overflow incontinence?
leakage that occurs when the quantity of urine stored in the bladder exceeds its capacity. Often occurs without the urge to urinate
risk factors for overactive bladder
-age > 40
-DM
-prior vaginal delivery
-obesity
-neurologic conditions
-drugs that increase incontinence (alcohol, cholinersterase inhibitors, diuretics, sedatives)
non-drug treatments for overactive baldder
-1st line is behavioral therapy: bladder training, delayed or scheduled voiding, pelvic floor muscle exercises, fluid management
Urge incontinence/mixed incontinence therapy
-1st line drugs include anticholinergics (oxybutynin) or beta -3 receptor agonist (mirabegron),
-onabotulinumtoxinA (Botox) has higher efficacy, but is not 1st line
Anticholinergic drugs for OA
-oxybutynin (Ditropan) 5 mg PO BID
-Tolterodine (Detrol) 1-2 mg
-Solifenacin (Vesicare) 5-10 mg
CI: narrow angle glaucoma
Warnings: agitation, confusion, drowsiness, blurred vision
SE: dizziness and drowsiness, xerostomia, constipation
Anticholinergic Side effect: Peripheral
-dry mouth
-dry eyes/blurred vision
-urinary retention
-constipation
-tachycardia
Anticholinergic Side Effect: Central
- sedation
-dizziness
-cognitive impairment
Decreasing risk of dry mouth
-dry mouth is a major reason that pts fail to comply with anticholinergic tx
-choosing a tx that minimizes dry mouth can improve adherence:
–> try extended-release formulations (lower risk than IR formulation)
–> try oxybutynin gel or patch (lower risk than oral formulation)
–> beta-3 agonists have a lower incidence of dry mouth and can be helpful in pts who cannot tolerate anticholinergics
–> try non-drug options to help with symptoms: avoid mouthwashes with alcohol, use ice chips, water, sugar-free candy or gum
Beta-3 agonists for OA use
-relax the detrusor muscle and increase bladder by activating beta-3 receptor (less dry mouth)
Mirabegron (Mybetriq): 25-50 mg daily
Vibegron (Gemtesa) 75 mg PO
Warnings: urinary retention in pts BPH, mirabegron can inc BP
-SEs: headache, constipation, diarrhea, dizziness
Monitoring: urinary symptoms, BP
Nocturia Treatment
-Desmopressin (DDAVP) 0.2-0.6 mg at bedtime
-SL tablet (Nocdurna) females: 27.7 mcg, males: 55.3 mcg
BBW: hyponatremia
CI: fluid retention
warnings: do not use with nasal conditions
Monitoring: serum Na
IV fluids: Crystalloids
-less costly and generally have fewer have fewer adverse reactions than colloids.
-balanced solutions may be preferred in certain disease states, such as sepsis, since the chloride load from a sodium chloride solution can be high enough to contribute to cellular injury, including renal damage
–> 5% dextrose (D5W)
–> 0.9% NaCl
–> Lactated Ringer’s
IV Fluids: Colloids
-large molecules (typically protein or starch) dispersed in a solution; they primarily remain in the intravascular space and inc oncotic pressure.
-provide greater intravascular volume expansion than equal volumes of crystalloids, but are more expensive and have not shown a clear clinical benefit
–> albumin 5%, 2.5%
Hyponatremia
-Na < 135 mEq/L normal
-not usually symptomatic until the sodium is <120 mEq/L
-symptoms most often result from cerebral edema and increased intracranial pressure, and can range from mild-moderate to sevre seizures, coma and resp arrest
Hypotonic hypervolemic hyponatremia
caused by fluid overlaod (cirrhosis, HF, renal failure)
-diuresis with fluid restriction is the preferred tx
Hypotonic isovolemic (euvolemic) hyponatremia
-can be caused by the syndrome of inappropriate antidiuretic hormone (SIADH)
-tx includes diuresis, restricting fluids and stopping drugs that can induce SIADH
Hypotonic hypovolemic hyponatremia
-can be caused by diuretics, salt-wasting syndromes, adrenal insufficiency, blood loss, vom/diarrhea
-tx is to correct the underlying causes and stop the intake of hypotonic solutions
How shoudl hyponatremia be corrected?
-correcting more rapidly than 12 mEq/L/24 hr can cause osmotic demilniation syndrome (ODS) or centeral pontine myelinolsis- which causes paralysis, seizures and death
-admin of desmopressin reduced water diuresis and can help avoid overcorrection
Arginine vasopressin (AVP) receptor antagonists: treating SAIDH
-increase excretion of free water while maintaining sodium
-Tolvaptan (Samsca) 15 mg po daily (limited to < 30 d due to hepatotoxicity)
BBW: should be initiated and re-initiated in a hospital, overly rapid correction is associated with ODS
Warnings: hepatoxicity
SE: thirst, nausea, dry mouth, polyuria
Monitoring: rate to Na increase
Hypernatremia
Na > 145 mEq/L is associated with a water deficit and hypertonicity
-hypovolemic hypernatremia is caused bt dehydration, vomiting or diarrhea and is treated with fluids
-hypercolemic hypernatremia is caused by intake of hypertonic fluids and is treated with diuresis
-Isovolemic (euvolemic) hypernatremia is frequently caused by dm insipidus, which can dec antidiuretic hormone (ADH), treated with desmopressin
IV potassium
-can be fatal id administered undiluted or via IV push
-when hypokalemia is resistant to tx, serum magnesium should be checked
-mag is needed for K uptake- replace first when both hypokalemia and hypomagnesemia are present
IV IG (gammagard, Gammunex-C, Octagam)
-given as a plasma protein replacement therapy for immune-deficient pts who have decreased or abolished antibody production abilities
BBW: acute renal dysfunction can occur, thrombosis
SEs: infusion reaction, renal failure or blood dyscrasias
–> pts should be asked about past IVIG infusion, a slower titration and premedication my be needed
Dopamine Dosing
Low (renal): 1-4 mcg/kg/min (dopamine-1 agonist)
Medium: 5-10 mcg/kg/min (beta-1 agonsit)
High: 10-20 mcg/kg/min (alpha-1 agonist)
Epinerprine MOA
-alpha-1
-beta-1
-beta-2 agonist
should be used IV push: 0.1 mg/mL
IM: 1 mg/mL
Norepinephrine MOA
-alpha-1 agonist activity > beta-1 agonist activity
Vasopressin MOA
vasopressin receptor agonist
Vasopressors class Safety/SE/monitoring
BBW: dopamine and NE - vesicants when administered IV; treat extravasation with phentolamine
SEs: arrhythmias, tachycardia, nescrosis, bradycardia (phenyl), hyperglycemia (epin)
Monitoring: MAP
–> all vasopressors should be administered via central line
Vasodilator: Nitroglycerin
-used when there is active MI or uncontrolled hypertension, limited to 24-48 hrs due to tachyphylaxis
-low dose = venous vasodilator, high dose = arterial
CI: SBP < 90, use with PDE-5 inhibitor
SE: headache, tachycardia, tachyphylaxis
-requires a non-PVC container (glass, polyolefin)
Vasodilator: Nitroprusside (Nipride)
-has equal arterial and venous effects)
[NOT used in active MI (steals the blood) has better BP effect than nitro, metabolism results in thiocyanate and cyanide formation = toxicity]
(hydroxyocobalamin can be admin to reduce the risk of thiocyanate toxicity, sodium thiosulfate + sodium nitrite is used for cyanide toxicity)
BBW: cynaide, hypotension - should be diluted w/ D5W
SE: heachadem tachycardia, thiocyanate/cyanide toxicity
–> requires light protection, use only clear solutions to admin, a BLUE color indicated cyanide (DO NOT USE)
Inotropes: Dobutamin & Milronine
-increase the contractility of the heart
D: beta-1 agonsit that inc HR and the force of myocardial contraction = inc CO
M: selective phosphodiestrase-3 inhibitor in cardiac and vascular tissue, produces inotropic effects with sig vasodilation
–> should only be used when BP is adequate b/c they produce vasodilation
General principles for treating septic shock
-target a mean arterial pressure (MAP) of > 65 (MAP = [(2 x DBP) + SBP]/3
-fill the tank: optimized preload with IV crystalloids (LR)
-squeeze the pipe and kick the pump: alpha-1 agonist activity (peripheral vasoconstriction) to inc SVR, beta-1 agonist activity to inc myocardial contractility and CO
(broad spectrum abx and IV crystalloids, can use NE if needed)
Common causes of ICU infections : Mechanical ventilation
-called respirators, air flows into the trachea through an endotrachial tube (ET) places through the mouth or nose.
–> inc time on ventialator = inc risk of infection (including lung)
-pseudomonas thrive in moist air in ventalators
Common causes of ICU infections: Indwelling urinary catheter
inc time on foley = inc risk of infection
Treating acute decompensated heart failure
- pts with edema, JVD and/or ascites = volume overload –> loop diuretics, vasodilators can be added (NTG, nitro)
- pts with dec renal function, AMS and/or cool extremities = hypoperfusion –> inotropes (dobutamine, milrinone), can add vasopressor if pt becomes hypotensive (dopa, NE, phenyl)
-pt experiences BOTH volume overload and hypoperfuson –> combo og agents
Agitation/sedation meds in ICU: Dexmedetomidine (Precedex)
-alpha 2 adrenergic agonist
SE: hypo/hypertension, bradycardia, dry mouth, nausea, constipation
-monitor: BP,HR, sedation scale
–> does not require refrigeration
–> duration of infusion should NOT exceed 24 hrs
–> use for sedation in intubated and non-intubated pts
Agitation/sedation meds in ICU: Propofol (Diprivan)
-short acting general anesthetic
CI: hypersensitivity to egg, soy
SE: hypotension, apnea, hypertriglyceridemia, green urine/hair/nails, propofol-related infusion syndrome
Monitor: triglycerides
–> shake well
–> potential for bacterial growth; discard vial and tubing within 12 hrs of use
–> oil in water emulation provides 1.1kcal/ml
Agitation/sedation meds in ICU: Lorazepam (ativan)
-injection is formulated in propylene glycol; total daily dose as low as 1 mg/kg/day can cause propylene glycol toxicity (ARF)
Agitation/sedation meds in ICU: Midazolam (Versed)
benzo
-BBW: resp depression
-CI: do not use with potent CYP3A4 inhibitors
SE: hypotension
Monitoring: BP, HR, RR, sedation scale
–> can accumulate in obese pts and renal impairrment
Risk factors for development of stress ulcers
-mechanical ventilation > 48 h
-Coagulopathy
-sepsis
-traumatic brain injury
-major burns
-acute renal failure
-high dose systemic steroids
Commonly used anesthetics
Local: lidocaine (xylocaine)
Inhaled: Desflurane (Suprane), sevoflurane
Injectable: Bupivacaine (Marcaine), Ropivacaine (Naropin)
Neuromuscular Blocking Agents: depolarizing = Succinylcholine (Anectine, Quelicin)
-short acting, fast onset (30-60sec)
-binds to and activated the ACh receptors and desensitizes them
-reserved for intubation and is not used for continuious neuromuscular blockade.
-has been associated with causing malignant hyperthermia
Neuromuscular Blocking Agents: non-depolarizing (5)
-bind aCh receptor, blocking the actions of endogenous ACh- pts cannot breath, move or blink
–> Atracurium: short t1/2, intermediate-acting, hofmann elim
–> Cisatracurium: short t1/2. interm-acting, hofmann
–> Pancuronium: long acting, can accumulate in renal/hepatic dysfunction, inc HR
–> Rocuronium: interm
–> Vecuronium: interm, can accumulate
Hemostatic agents: Tranexamic acid (Cyklokapron)
-inhibits fibrinolysis or enhancing coagulation
SE; vascular occulusion, thrombosis, retinal clotting
–> oral is approved for heavy menttrual bleeding, injection approved for hemophilia
Hemostatic agents: Recombinant Factor VIIa (NovoSeven RT)
-inhibits fibrinolysis or enhancing coagulation
BBW: risk of thrombotic events
–> FDA approved for hemophilia and factor VII deficiency
When to seek urgent care for a child
-age <3 m: temp of 100.4/38 (rectal)
-age 3-6 m: temp 101/38.3 (rectal)
-age > 6 m: temp 103/39.4 (rectal)
-ant cough/cold that worsens or does not improve in several days
-unusual, severe pain
-blood in stool or urine
-inability to sleep or drink
-rash that looks severe or rash w/ fever
-abrasions/cuts that are dirty or deep
-limping of unable to move extremity
-seizures
what drugs can help the patent dutuc arterious in new born heart to close?
NSAID- IV indomethacin or ibuprofen) by blocking the prostaglandins that keep the PDA open
–> NSAIDs should not be used in 3rd trimester b/c they can cause the PDA to close prematurely
Select OTC products for infants: Fever (Acetaminophen)
-10-15 mg/kg/dose every 4-6 hr (max 75 mg/kg/day)
–> most oral formulations are 160mg/5ml
Select OTC products for infants: Fever (Ibuprofen)
-5-10 mg/kg/dose every 6-8 hrs (max 40 mg/kg/day)
–> infant drops = 50 mg/1.25 ml
–> childrens suspension = 100 mg/5 ml
**indicated for infants 6 months and UP
Select OTC products for infants: Intestinal gas (Simethicone)
-20 mg 1-4 times/day PRN
–> adminster after meals and at bedtime for mild gas
–> shake drops, can mix with water, formula or other liquids
Select OTC products for infants: Nasal dryness/congestion (saline solution)
2-6 drops per nostril PRN
Select OTC products for infants: Constipation
-PEG (miralax) : age > 6 mon: 0.4 mg/kg, max 17 gram, dissolve in 4 oz of water
-Glycerin supp: 1 ped supp per dose
Bacterial meningitis pathogens: < 1 month y/o
-streptococcis agalactiae (group B strep), E. coli, listeria monocytogens, Klebsiella
Empiric tx: ampicillin + cefotaxime or ampicillin + aminog (gentamicin)
Bacterial meningitis pathogens: 1-23 month y/o
-streptooccus pneumoniae, Neisseria meningitidis, S, agallactiae, Haemophilus influenzae, E. coli
Empiric TX: vanco + 3rd gen ceph (ceftriaxone or cefotaxime)
Bacterial meningitis pathogens: > 2 y/o
-N. meningitidis, S. pneumoniae
Empiric TX: vanco + 3rd gen ceph (ceftriaxone or cefotaxime)
Who should recieve Palivizumab (Synagis)? (vaccine for RSV)
-dosed monthly at 15 mg/kg per dose given via IM
*in the first yr of life:
–> premature infants born at < 29 weeks gestation
–> premature infants born < 32 weeks gestation eith chronic lung disease who are < 12 months og age
–> infants < 12 months of age with certain heart conditions
Treatment of Croup
-viral infection caused by inflammation of upper airway
–> signs: inspiratory stridor, barking cough, and hoarseness (most common in children < 6 y/o)
-systemic steroids (dexamethasone 0.6 mg/kg dose x 1)
Treatment for nocturnal enuresis: Desmopresson (PO)
-synthetic analog of antidiuretic hormone - will decrease nocturnal urine production
-start at 0.2 mg PO QHS, can titrate to 0.6 mg QHS
CI: hyponatremia
SE: headache
–> limit fluids starting 1 hr before dose and until the next am
Drugs to avoid in peds
CI:***
-codeine in age < 12
-Tramadol in age < 12
-Promethazine in age < 2
-Ceftriaxone in neonates (0-28 days)
NOT REC:
- aspirin in children and teenagers
-quinolones ( AE on bones and cartilage)
-tetracylcines in age < 8 (stain teeth)
-OTC teeth medications contianing benzocaine in age < 2
-OTC cough and cold preps in age <2 yrs
what are 2 primary toxins that can lead to accidental overdose in children?
-Iron and acetaminophen
Vaccine preventable disease in childhood: Measles
-Koplick spots in mouth, maculopapular rash
-transmission is airborne
-Prevention: MMR vaccine
Vaccine preventable disease in childhood: Mumps
-swollen salivary glands
-Prevention: MMR vaccine
Vaccine preventable disease in childhood: Rubella
-fever, rash, swollen glands
-Prevention: MMR vaccine
Vaccine preventable disease in childhood: Polio
-nerve damage, cannot walk
Prevention: IPV vaccine
Vaccine preventable disease in childhood: Pertussis
-“whoop” sounding cough
Prevention: DTaP vaccine
Vaccine preventable disease in childhood: Rotavirus
-diarrhea, fever, vomiting
Prevention: RV vaccine
Vaccine preventable disease in childhood: Chicken pox
itchy, rash, fever
Prevention: varicella vaccine
What is cystic fibrosis?
-incurable, hereditary disease cause by a mutation in the gene for the protein CFTR. –> causes thick, viscous secretions in lungs, pancreas, liver and intestine
-average lifespan is 35-40 yrs, diagnosed by age 2 (new born screenig at 2-3 days, sweat chloride test, high = CF)
-symptoms: salty skin, poor growth/weight gain, coughing, SOB
inhaled meds for CF pt: order is IMPORTANT**
1) inhaled bronchodilators (albuterol) = opens the airway
2) hypertonic caline (Hypersal) = mobilizes mucus to improve airway clearance
3) Dornase alfa (Pulmozyme) = decreases viscosity of (thins) mucus to promote airway clearance
4) chest physiotherapy = mobilizes mucus to improve airway clearance
5) Inhaled abx = controls airway infection
Treatment for lung complications and infection in CF: airway clearance therapies (inhaled)
options: albuterol, hypertonic saline, Dornase alfa*
–>DA: works by degrading extracellular DNA in the lungs to decrease viscosity of mucus
CI: hypersensitivity to chinese hamster ovary products
SE: chest pain, fever, rash
-store ampules in the fridge, protect from light, do not mix with any other drug in the nebulizer
Treatment for lung complications and infection in CF: abx (inhaled) to target Pseudomonas aeruginosa: Tobramycin (TOBI)
-age > 6y/o
SE: ototoxicity, tinnitus, voice alteration, mouth and throat pain
–> give for 28 days on and 28 days off cycle
-do not mix with other drugs in neb
Whats in the name?: Lungs: Dornase alfa/ Pulmozyme
-Enzyme!
-breaks down DNA strands into smaller pieces, thinning the mucus to make it easier to cough up
Treatment for lung complications and infection in CF: abx (inhaled) to target Pseudomonas aeruginosa: Aztreonam (Cayston) and Azatam (IV)
-age > 7 yrs, 75 mg via neb
SE: allergic reactions, bronchospasm, fever, wheezing, cough, chest discomfort
–> give for 28 days on, 28 days off
- do not mix with other drugs in neb
reatment for lung complications and infection in CF: oral obx ( to dec inflammation and exacerbations) Azithromycin (Zithromax)
-age > 6 yrs
SE: tinnitus, nausea, risk of QT prolongation
Whats in the name?: GI tract: Pancrelipase
-lipase, protease and amylase–> needed to break down fats, proteins and starches
Pancreatic enzyme products in CF tx: Pancrelipase (creon, viokace, zenpep)
age < 1 yr: varies
age 1-3 y: lipase 1000u/kg/meal
age > 4 y: lipase 500 u/kg/meal
MAX: < 2500 u/kg/meal
SE: abdominal pain, flatulance, nausea
Common issues with pancreatic enzyme products
-pancreatic enzyme replacement helps pts with CF digest food, maintain weight and improve nutrient absorption
-PEP formulations are not interchangable
-Viokace is the only PEP that is a tab, must be given with a PPI
-all others are capsules: do not cruch, or chew
-take PEPs before or with all meals and snacks, high-fat meals may require higher doses (use 50% of mealtime dose with snacks)
-protect from moisture, dispense in original containers (exceptions: zenpep and some creon strengths), do not refigerate
Induction Immunosuppression: Antithymocyte Globulin (Atgam- equine, Thymogloblin- rabbit)
-binds to antigens on T-lymphocytes and interferes with their function
-BBW: anaphylaxis
-SE: infusion reaction
–> premedicate to lessen infusion-related reactions
Induction Immunosuppression: IL-2 receptor agonists : Basiliximab (Simulect)
-20 mg iV on the day of transplant (day 0), then repeat dose on post operative day 4
SE: inc BP, fever, stomach upset/n/v
What is used for maintenance immunosuppression in transplant?
-a calcinerurin inhibitor- cyclosporine or tacrolumus (this is 1st line)
-an anti proliferative agent such as mycophenolate (1st line) or azathioprine
-w/ or w/o steroids
Calcinerurin-inhibitors: Cyclosporine (Gengraf, Neoral, Sandimmune)
-suppresses cellular immunity by inhibiting T-lymphocyte activation
BBW: nephrotoxicity, inc risk of lymphoma, malignancies, skin cancer
SE: inc BP, nephropathy, hyperkalemia, hypomag, QT prolongation
Monitor: trough, serum electrolytes, renal function, BP,
Calcinerurin-inhibitors: Tacrolimus (Prograf)
-1st line!! suppresses cellular immunity by inhibiting T-lymphocyte activation
BBW: inc risk of infections
SE: inc BP, nephrotoxicity, inc BG, hyperkalemia, QT prolongation
Monitor: serum electrolyyes, renal function, LFTs, BP, blood glucose
Anti-proliferative agents: Mycophenolate Motetil (CellCept). Mycophenolic Acid (Myfortic)
-inhibit T- and B-lymphocyte proliferation by altering purine nucleotide synthesis
BBW: inc risk of infection, lymphoma, skim malignancies
SE: diarrhea, GI upset
–> not interchangeable (CellCept 500 mg = Myfotic 360 mg)
–> CellCept IV is stable in D5W only
–> decreases efficacy of oral contraceptives
Mammalian target of rapamycin (mTOR) kinase inhibitors:
-Everolimus (Zortress) –> do not use within 30 days of transplant
-Sirolimus (rapamune) –> impaired wound healing
What drugs to use for induction Immunosuppressants in transplant
-Basiliximab, an interleukin (IL-2) receptor antagonist
-Antithymocyte globulin in pts at higher risk of rejection
-high dose IV steroids
What drugs to use for maintenance immunosuppressants in transplant
-the CNIs (tacrolimus then cyclosporine)
–> belatacept as alt to a CNI
-adjuvant medications given with a CNI (to achieve adequate immunosuppression while decreasing the dose and toxicity of the individual agents
–> antiprolifertave agents (mycophenolate or azathioprine)
–> mTOR inhibitors (everolimus or azathioprine)
-steroids at lower or tapering doses
Boxed warnings for transplant drugs
-infection risk: suppress the immune system
-cancer risk
Vaccine - preventable illness in transplant recipients
-influenza (inactivated, not live) annually
-pneumococcal vaccines in adults > 19 yrs: PCV20 x1, PCV15 x1 followed by PPSV23 x1 8 weeks later
-varicella vaccine
Key drugs that can cause weight gain
-antipsychotics (clozapine, olanzapine, risperidone, quetiapine)
-DM drugs (insulin, sulfonylureas, meglitinides, thiazids)
-divalproex/valproic acid
-gabapentin/pregablin
-lithium
-mirtazapine
-steroids
-TCAs
-hypothyroids
Select drugs/conditions that can cause weight loss
-ADHD drugs
-bupropion
-GLP-1 (-tide)
-pramlintide
-Roflumilast
-SGLT2 (-flozin)
-Topiramate
-Tirzepatide
-Conditions: hyperthyroidism, celiac disease, inflammatory bowel disease
Rx weight loss drugs to avoid in: HTN
-contrave: contraindicated in ppl with uncontrolled BP (contains bupropion)
-caution with Qsymia: monitor HR (contains phentemine)
Rx weight loss drugs to avoid in: Depression
-Contrave: suicide risk (contains bupropion)
RX weight loss drugs to avoid in: seizures
-Contrave: lowers seizure threshold (contains bupropion)
caution with Qsymia: must taper off slowly if used (contains topiramate)
Rx weight loss drugs to avoid in: taking opioids
-Contrave: blocks opioid receptors (contains naltrexone)
Weigh loss medication: Phentermine/Topiramte ER (Qsymia)
P: sympathomometic (stimulant): release of NE stimulates the satiety center which dec appetite
T: inc satiety and dec appetite, possibly by inc GABA, blocking glutamate receptors and/or inhibition of carbonic anhydrase
CI: glaucoma, pregnancy (REMS due to teratogenic risk)
SE: tachycardia, insomnia, vision problems
–> taper off due to seizure risk
Weight loss medication: Naltrexone/Bupropoin (Contrave)
N: dec food craving
B: dec appetite
CI: pregnancy, chronic opioid use, uncontrolled HTN, seizures, use of MAOi within 14 days
–> fatty food increases drug levels: do not take with high-fat meal
Weigh loss medication: GLP-1 Liraglutide (saxenda) and Semaglutide (wegovy) [ozempic and rybelsus for DM]
BBW: risk of thyroid c-cell carcinoma
CI: personal or fam hx of medullary thyroid carcinoma
warnings: pancrestitis, hypoglycemia
SE: nausea
–> may need to decrease insulin or sulfonylurea/meglitinide doses to dec risk of hypoglycemia
Weight loss medications: Lipase inhibitors- Orlistat (Xenical, Alli- OTC)
-dec absorption of dietray fat by ~30%
CI: pregnancy
Warnings: liver damage, inc urinary oxalate/kidney stones
SE: GI, farts w/ dischage, fatty stools
–> take vit A,D,E,K and beta carotene at bedtime
–> must be used with a low-fat diet
Weight loss medications: Phentermine (Adipex-P)
-appetite supp: release NE stimulates the satiety center which dec appetite
CI: cardiovascular disease, hyperthyroidism, glaucoma, pregnancy
SE: tachycardia, agitation, inc BP
–> use short term, up to 12 hrs
Bariatric surgery for weight loss
-guidelines rec for adults with BMI > 40 kg/m^2 or with a BMI > 35 with an obesity- related condition
how to treat an acetaminophen overdose?
-antidote = N-acetylcysteine (NAC)
–> glutathione precurser
–> administered IV or orally
NSAID BBWs
-GI risk: inc the risk of GI bleed and ulceration
-CV risk: can inc the risk of MI and stroke (all non-selevtice NSAID except aspirin)
-CABG Surgery: NSAIDs use is CI after this, antiplatelet therapy (Apirin) is rec
SEs of NSAIDs
-can decrease renal clearance
-inc blood pressure
-cause premature closure of the ducta arteriousus, do NOT use in 3rd trimester
-nausea
-photosensitivity
NSAIDs and the Ductus Arteriosus*
-before birth the DA connects the pulmonary arter to the aorta, allowing oxygenated blood to flow to the baby, by bypassing the immature lungs
–> do NOT use NSAID in the 3rd trimester of pregnancy- can prematurely close the DA
-after birth, the DA should close on its own,
–> IV NSAIDs (Indomethacin, ibuprofen) can be used within 14 days after birth to close a DA
Non-aspirin NSAIDs (COx-1, and COX-2 non selective)
–> all have GI risk, CV risk, and risk in post-operative CABG
-Ibuprofen (Advil, caldolor, Motrin): limit self-tx to 10 days, can cause SJS/TENS
-Indomethacin (Indocin): high risk for CNS effects
-Naproxen (Aleve): can be dosed BID
-Ketorolac (Toradol): MAX conbined duration IV/IM and PO = 5 days
Cox-2 selective NSAIDs
-lower risk for GI complications, inc risk of MI/stroke, same risk for renal complications
-Celecoxib (Celebrex) : CI with sulfonamide allergy, highest COX-2 selectivity
-Diclofenac (voltaren) BBW: avoid in femals of childbearing potential (misoprostol is used to replace the gut-protective prostaglanidins to dec GI risk
-Meloxicam (Mobic)
Salicylate NSAIDs
-Aspirin/Acetylsalicylic Acid (Ascriptin, Bufferin, Ecotrin)
–> avoid in children and teens with any viral infection due to potential risk of Reye’s syndrome
SE: PPIs may be used to protect the gut
-salicylare overdose can cause tinnitus
NSAID drug interactions
-additive bleeding risk
-NSAIDs can inc levels of lithium and methotrexate
Opioids boxed warnings
-addiction, abuse and misuse can lead to overdose and death
-respiratory depression
-use of opioids and benzo with other CNS depressants, including alcohol can cause death
-Morphine ER caps, Nucybnta ER, oxymorphone ER and hydrocodone ER caps: do not consume alcohol
-crushing, dissolving or chewing the long-acting products can cause delivery of potentially fatal dose
-life-threatening neonatal opioid withdrawal can occur with porlonged use during pregnancy
opioids and non-cancer pain
-opioids are not first line for chronic pain tx
–if using opioid, start with immediate release: start low and go slow
– evlauate risk factors
–use adjunctive meds to enable a lower opioid dose
–avoid bezos
opioid allergy
-codeine: hydrocodone, oxycodone
-Morphine: hydromorphone, oxymorphone
-Buprenorphine: herion
Opioid-induced respiratory depression risks
OIRD risk factors:
-hx of previous overdose
-substance use disorder
-using large doses (> 50 mg morpine)
-use w/ benzos, gabapentin, or pregablin
-comorbid illness, sich as resp or psychiatric disease
–> naltrexone should be readily available to pts with elevated risk for ORID
Opioid-induced Constipation
-opioids reduce GI tract peristalsis, making it difficult to have a bowel movement
-OIC does not improve over time without tx: it must be anticipated and treated
–> stimulant (senna, bisacodyl) or osmotic (polyethylene glycol) laxatives are the typical first line
-if laxitives are not sufficient, PAMORAs can be used
–> lubiprostone can be used following a trial of laxatives
TX of opioid-induced constipation: PAMORAs
-block opioid receptors in the gut to reduce constipation w/o affecting analgesia (only affective when constipation is secondary to use of an opioid)
–Methylnaltrexone (Relistor) : only for pts who have failed OTC laxatives
–Naloxegol (Movantik)- d/c all laxatives prior to use
TX oc opioid-induced constipation: Chloride channal activator
Lubiprostone (Amitiza)
Opioid over dose management
S&S: extreme sleepiness, slow or shallow breathing, fingernails or lips turning blue or purple, extremely small pupils, slow heartbeat and/or blood pressure
–> give naloxone and call 911
-narcan: nasal spray, slower onset of action than injection (naltrexone)
drugs for opioid use disorder:
-bupernorphine (C-3)
-methadone
oral adjuvants for neuropathic pain
-gabapentin (Neurontin)
-pregablin (lyrica)
-Carbamazepine (tegretol)
-amitriptyline
-duloxetine (cymbalta)
oral adjuvants for musculoskeletal pain
-baclofen (Lioresal)
-cyclobenzaprine (Amrix, Fexmid)
-tizanidine (zanaflex)
-carisoprodol (soma)
-methocarbamol (Robaxin)
Topical adjuvants for musculoskeletal pain
-lidocaine
-lidocaine 5% (Lidoderm)
-capsaicin (zostrix,) - dec substance P
-methyl salicylate (bengay, icyhot)
-trolamine (aspercreme)
Common Migraine Triggers
-hormonal changes in women: flunctuations in estrogen, progestrin only pills are rec for migraine with aura due to stroke risk with estrogen-containg pills
-foods: alcohol, cheeses, chocolate, aspartame, overdose of caffeine, MSG, salty foods and processed foods
-stress
-sensory stimuli: bright lights, sun glare, loud sounds and certain scents
-changes in wake-sleep patterns
-changes in environment
how to make a diagnosis of migraine
When an adult has at least 5 attacks fulfilling:
- headaches last 4-72 hrs and recur sporadically
-headaches have > 2 of the following characteristics: unilateral location, pulsating, mod-severe pain and aggravated by routine physical activity
-one of the following occurs: nausea/vomiting, photophobia, and phonophobia (sensitivity to sound)
acute drug tx of migraine
OTC: acetaminopen, aspirin, advil, naproxen, excedrin migraine
RX: NSAIDs, triptans, CGRP receptor antagosnits
Triptans used for migraine tx
-vasodilator cranial blood vessels, inhibit neuropeptide release and decrease pain transmission, 1st line for acute tx–> take at the first sign of headache (all have tablet formualtion)
– Rizatreptan (Maxalt-MLT) ODT
– Sumatriptan Nasal, injection
– Imitrex
– Onzetra Xsail
– Zolmitriptran (Zomig) ODT, nasal
Triptan class safety/SE/Monitoring
CI: cerebrovascular disease, uncontrolled HTN, ischemic heart disease
Warning: inc blood pressure, serotonin syndrome
SE: paresthesia, tripatan sensations (pressure or heaviness in the chest or pressure in the neck region)
–> all SC injections are preferred in lateral thigh or upper arm, protect from light
Triptan drug interactions
-risk of serotonin syndrome
-Suma, riza and zolmi are CI with MAOi (or within 2 weeks of stopping)
Migraine tx: Ergotamine drugs
-nonselective agonist of serotonin receptors causes cerebral vasoconstriction, in pts who do not find benefit with a triptan, ergotamine is generally used next
–> Dihydrogotamine (DHEA, Mogranal): injection/nasal spray
BBW: use with CYP3A4 inhibitors
CI: uncontrolled HTN, ischemic heart disease, pregnancy
Migraine TX: CGRP receptor antagonsits
-contribute to vasodilation and neurogenic inflammation in the pathogenesis of migraines; blocking the CGRP receptor helps reduce or eliminate migraine pain
–> Ubrogeapant (ubrelvy): approved to treat acute migraine attacks
–> rimegepant (Nurtec): approved to prevent and treat acute migraine attacks
Prophylactic drug treatment of migraine
-BBs (propranolol, meto tat, meto succ, timolol)
-Antieliptics (topiramate, valporic acid)
-CGRP receptor antagonsits (atogepant, epitinezumba, erenumab, nurtec)
-antidepressants (amitriptyline)
-monophasic OCs, NSAIDs or a triptan (frova, nara) can be started prior to menses and continued for 5-7 days
Botulimun toxin for migraine tx
-botox injections are used from prophylaxis
chronic migraines only (> 15 headache days per month)
Drugs that increase uric acid (inc risk for gout)
-aspirin, lower doses
-clacineurin inhibitors (tacrolimus and cyclosporine)
-diuretics (loops or thiazides)
-niacin
-pyrazinamide
-select chemotherapy
-select pancreatic products
Gout treatment basics
Treat acute pain with anti-inflammatory drugs:
- colchicine
-steroids
-NSAIDs
Treat chronically to prevent future attacks:
-XOI: allopurinol (preferred) or febuxostat
If XOI didnt work well enough and UA remins > 6:
-add on probenecid or lesinurad to daily XOI
-replace the XOI with IV pegloticase (Krystexxa)
Acute Gout Attack Therapy: Colchicine (Colcrys)
CI: P-gp or strong CYP3A4 inhibitors with renal and/or hepatic imparment
Warnings: myelosuppression, inc myopathy risk
SE: diarrhea, nauseam myopathy, neuropathy
–> start within 36 hrs of symptom onset
–> wait 12 hrs after a tx dose before resuming proph dose
Acute Gout Attack therapy: NSAIDs
-Indomethacin (Indocin)
-Naproxen (Aleve)
-Celecoxib (Celebrex)
Acute gout attack tx: Steroids
-prednisone/Prednisolone
-methylprednisolone
Chronic urate lowering therapy: Xanthine oxidase inhibitors
-Allopurinol (Zylooprim, Aloprim): SJS.TENs reaction, SE: acute gout attack
-Febuxostat (Uloric) BBW: cardiovascular disease
